POS1461 GIANT CELL ARTERITIS-RELATED STROKE IN A MAN WITH ELDERLY-ONSET RHEUMATOID ARTHRITIS
Authors: M. Hng, M. Dey, R. Moots
Journal: Annals of the Rheumatic Diseases (2022)

Background Giant cell arteritis-related stroke is rare, with high early mortality and major morbidity in survivors. Objectives To increase the awareness of coexistence of giant cell arteritis-related stroke and rheumatoid arthritis. Methods A case report and discussion. Results A 73 year-old man with seronegative elderly-onset rheumatoid arthritis (EORA) presented to the emergency department (ED) with a one week history of frontal headache, vomiting and dizziness. He had multiple cardiovascular comorbidities and took multiple medications, including methotrexate and sulfasalazine. He also had long-standing history of thrombocytopenia without requiring any treatment. Neurological examination performed in the ED was unremarkable. His C-reactive protein (CRP) was 69mg/L and erythrocyte sedimentation rate (ESR) 82mm/hour. Computed tomography (CT) of the brain was normal. The headache settled with analgesia. A diagnosis of probable tension-type headache, with underlying active EORA, was made. One month later, he presented to an ophthalmologist with recurrence of headache associated with visual disturbance and was diagnosed with giant cell arteritis (GCA). Both CRP (77mg/L) and ESR (85mm/hour) remained raised. Neither temporal artery biopsy nor temporal artery ultrasound were possible due to the coronavirus disease 2019 (COVID-19) pandemic. The headache and visual symptoms resolved completely a week after prednisolone 60mg daily was prescribed. In parallel, the CRP dropped to 2mg/L and ESR 16mm/hour. The patient’s glucocorticoid dose was then tapered. While on prednisolone 20mg daily, about 3 weeks later, he developed slurred speech and generalized weakness. Examination showed cerebellar signs and MRI brain showed acute cerebellar infarct. He was treated pragmatically as an atherosclerotic stroke with clopidogrel, and the steroid was rapidly tapered in view of absence of headache and normalization of inflammatory markers. Four weeks later, he was noted to have persistent confusion and unsteadiness of gait. CRP was elevated at 92mg/L. An urgent positron emission tomography-CT (PET-CT) scan showed inflammation in the vertebral arteries [Figure 1] and cerebellar stroke. Prednisolone 40mg daily was restarted which led to a rapid improvement in his symptoms and normalization of inflammatory markers. The glucocorticoids were tapered in a slower manner this time. Figure 1. Fused axial image of a PET-CT scan demonstrating increased uptake in the region of the left vertebral artery within the vertebral foramen. A diagnosis of GCA-related cerebellar stroke with vertebral vasculitis was made and, with glucocorticoids, the patient made a good clinical recovery. His inflammatory joints pain also improved in parallel. Conclusion Stroke or transient ischemic stroke are rare complications, reported in 2.8-16% of patients with active GCA. Most studies report strokes as occurring between the onset of GCA symptoms and 4 weeks after commencement of glucocorticoids 1-3 . Vertebrobasilar territory is involved in 60–88% of cases of GCA-related stroke 1-3 . In contrast, the vertebrobasilar territory is affected only in 15-20% of atherosclerotic strokes 1,2 . One study reported fatal outcomes in 11 out of 40 patients (28%) with GCA-related stroke, 7 within 2-13 days of stroke 2 . To conclude, this case demonstrates that high-dose glucocorticoids with slower tapering were able to control GCA-related stroke due to vertebral vasculitis in patient with EORA on background methotrexate and sulfasalazine. References [1]Gonzalez-Gay MA, Vazquez-Rodriguez TR, Gomez-Acebo I, et al. Strokes at time of disease diagnosis in a series of 287 patients with biopsy-proven giant cell arteritis. Medicine. 2009;88(4):227-35. [2]de Boysson H, Liozon E, Larivière D, et al. Giant cell arteritis–related stroke: a retrospective multicenter case-control study. 2017;44(3):297-303. [3]Pariente A, Guédon A, Alamowitch S, et al. Ischemic stroke in giant-cell arteritis: French retrospective study. 2019;99:48. Acknowledgements We would like to thank Dr Lenetta Boyce for providing the PET-CT images. Disclosure of Interests None declared